Certificate of Doing Business Under Assumed Name

[Pages:1]Certificate of Doing Business Under Assumed Name ("D/B/A")

Ulster County Clerk's Office, 244 Fair Street, Kingston, NY 12401 (845)-340-3288 Nina Postupack, Ulster County Clerk ? countyclerk

PURSUANT TO SECTION 130 OF THE GENERAL BUSINESS LAW OF NEW YORK STATE

1. I certify that my name is (print name) ___________________________________________________________ 2. I live at ___________________________________________________________________________________ 3. I intend to do business in ULSTER COUNTY at the following address: ___________________________________________________________________________________________ in (city, town, village) _________________________________________, New York, (zip) _________________ 4. I will do business under the name______________________________________________________________ ___________________________________________________________________________________________ 5. I further certify that I am the successor in interest to the following person, who formerly used this name or names to conduct transact business (person's name) _______________________________________________ My Signature: ________________________________________________ Date: _________________________

*Print or type name under signature

*If under 21 years of age, state "I am _______ years of age"

STATE OF NEW YORK

)

COUNTY OF _____________ ) SS:

On this _____day of ______________________, 20_____, before me, the undersigned personally appeared

___________________________________________________________________________________________ personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity and that by his/her signature on the instrument, the individual, or the person upon behalf of the which the individual acted, executed the instrument.

_____________________________________________________________ (Signature of individual taking acknowledgment) ? Notary Public

Instructions: Use this form for a DBA by an INDIVIDUAL. Complete the form BUT DO NOT SIGN IT until you are in the presence of a Notary Public. My staff are Notaries and can witness your signature at no charge if you wish. Bring the form to the Ulster County Clerk's Office at 244 Fair St. in Kingston together with $25.00 cash or money order payable to "Ulster County Clerk's Office. A certified copy may be obtained at the cost of $5.00 per copy. Our office hours are 9:00 AM to 4:45 PM Monday through Friday except holidays. There are other forms for Partnerships filing DBA's as well as amendment and termination forms. The Partnership form is available in our office for a fee of $1.00. The amendment and terminations forms must be purchased at a legal supply store. Legal questions should be addressed to an attorney. We appreciate your business! Nina Postupack, Ulster County Clerk

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